Box 55 Association Accident Reporting Form

Complete this report promptly and notify the OIC and Safety Officer.

Incident details

Type of incident*

Slip / Trip / Fall Equipment Failure Chemical Exposure Smoke Inhalation Security Concern Vehicle Accident Other

Other incident type*Date of incident*Approximate time of incident*Severity level*Incident description*Street*Cross streetCity*Mile marker

Box 55 member involved — first nameBox 55 member involved — last nameVehicle involvedVehicle damage descriptionAccident circumstances

Do not be forceful when gathering this information; it may be included in the police accident report.

Other vehicle makeModelColorStateTagOther driver first nameOther driver last nameOther driver phoneOther driver address

Surface conditionsTask being performedType of shoesCause of fallChemical or substance involvedExposure detailsSymptoms or effects experienced

Did you seek medical attention?* Yes No

Medical care received ER EMS Urgent Care Primary Care Doctor

Did you refuse medical care?* Yes No

Reporter first name*Reporter last name*PositionEmailPhone number*Attach evidence photosJPEG, PNG, or WebP · up to 8 photos, 4 MB each.

Signature*

I confirm this information is correct to the best of my knowledge and that I notified the OIC and Safety Officer in a timely manner.*

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Incident date	Type	Severity	Location	Reporter	Evidence

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